肾血管平滑肌脂肪瘤的保留肾单位手术

目的　评估保留肾单位手术在肾血管平滑肌脂肪瘤治疗中的作用。　方法　回顾性分析 49例行保留肾单位手术治疗的肾血管平滑肌脂肪瘤患者资料 ,观察术前及术后肾功能、手术并发症及预后等。肿瘤剜除术 3 1例 ,肾部分切除 15例 ,原位灌注肾部分切除术 3例 ;其中 3例患者术前行选择性肾动脉栓塞术。　结果　切除肿瘤平均直径 6.0cm (2 .5～ 16.0cm) ,3例原位灌注肾部分切除术肿块直径分别为 10 .5cm、12 .0cm和 15.0cm。 49例术中平均失血量 3 10ml (50～ 10 0 0ml)。无手术并发症发生。术前及术后 10d血肌酐值比较差异无显著性 [(89± 2 6)mmol/Lvs (98± 3 4 )mmol/L ,P>0 .0 5]。 45例平均随访 3 6个月 (1～ 76个月 ) ,无肿瘤复发或需血液透析治疗者。　结论　保留肾单位手术是外科治疗肾血管平滑肌脂肪瘤的首选方法     

保留肾单位手术治疗肾错构瘤

目的：探讨肾错构瘤(RAML)行保留肾单位手术(NSS)治疗的有效性，对术后肾功能保存及肿瘤复发情况进行评估。方法：对35例RAML行NSS治疗患者的临床资料进行分析。结果：在有明显症状RAML17例患者中，最常见的症状或体征是疼痛(59％)、血尿(41％)、腹膜后出血(11％)、高血压(18％)等。其中有1例并发结节性硬化综合征。28例患者有正常的对侧肾(Ⅰ组)，7例患者为功能性孤立肾(Ⅱ组)，平均随访时间37(6～120)个月。所有手术在原位完成，术中无并发症，平均失血量400(150～800)m1。术后Ⅰ组、Ⅱ组平均肌酐分别为83．98μmol／L和169．73μmol／L。随访期间无患者出现肿瘤复发及需要透析治疗。结论：当RAML需要外科手术时，NSS是一种高成功率的方式。长时间随访未发现肿瘤复发并且在孤立肾患者术后有稳定的肾功能。     

巨大肾血管平滑肌脂肪瘤的保留肾单位手术治疗

目的：探讨提高手术治疗巨大肾血管平滑肌脂肪瘤效果的措施。方法：对13例巨大肾血管平滑肌脂肪瘤的患者,采用控制肾蒂血管和后控制肾蒂血管、术中出血回收回输技术、创面修复及生物蛋白胶粘合,切除巨大肿瘤,保留肾脏。肾盂破损的予以修复,同时置入双J管。结果：13例均成功地切除肿瘤组织,保留肾组织。肾盂修复置入双J管,术后无继发性出血和尿瘘发生。术后3个月复查,2例静脉肾盂造影肾脏显影良好,8例术后分别行B超和CT检查,提示肿瘤切除术后改变,血供无异常,血清肌酐、尿素氮正常。结论：综合应用创面修复技巧、血液回收回输技术及生物蛋白胶,可以有效地增加保留肾脏的机率。     

保留肾单位手术治疗肾癌(附46例报告)

目的:探讨保留肾单位手术治疗肾癌的安全性和疗效。方法:对1993年2月～2006年10月共46例采用保留肾单位手术的肾癌患者的临床资料进行回顾性分析,其中双侧肾癌4例,孤立肾癌3例,对侧肾有病变或潜在功能受损的肾癌25例,对侧肾正常的肾癌14例。结果:46例患者术前均未发现转移灶。术后组织病理学结果示肾透明细胞癌36例,颗粒细胞癌6例,混合性细胞癌4例。术后42例(91%)获随访,随访时间6～160个月,平均随访65个月。5、10年生存率分别为94%、86%。3例术后出现局部复发和远处转移。结论:保留肾单位手术治疗肾癌安全有效,手术指征可扩展至对侧肾脏正常的患者。     

Nephron-sparing surgery for renal cell carcinoma--long-term results

OBJECTIVES: Renal cell carcinoma (RCC) is most often treated using radical nephrectomy. However, in patients with only one kidney or with bilateral RCC, nephron-sparing surgery (NSS) is mandatory. NSS may also be undertaken in patients with a normal contralateral kidney, providing that the tumour is fairly small and not unfavourably located. The aim of the present study was to determine the long-term results in patients treated with NSS for RCC. MATERIAL AND METHODS: We reviewed the records of 87 patients with RCC subjected to NSS between 1980 and 1999. The survival rate was determined, as well as the tumour grade (Skinner classification) and stage (1992 World Health Organisation classification). RESULTS: Cancer-specific survival, in patients with no demonstrable distant metastases and regardless of stage and grade, was 80% and 75% at 5 and 10 years, respectively. Long-term survival was significantly dependent on tumour stage and grade. CONCLUSION: In this patient series, long-term survival did not differ from the results obtained using radical nephrectomy, judging from the available literature. An exception was found in patients with high-stage RCC, where NSS appeared to be a less favourable procedure. We therefore recommend that NSS should be performed in cases with bilateral tumour disease or an absent/malfunctioning contralateral kidney. NSS may also be considered in cases of low-stage RCC with a normal contralateral kidney, especially in patients with local or systemic conditions that may adversely affect renal function in the future.     

小肾癌的保留肾单位手术治疗

目的 探讨保留肾单位的肾部分切除手术治疗小肾癌的安全性和合理性。方法 对48例小肾癌患者行保留肾单位的肾部分切除术。男29例，女19例。平均年龄42岁（24～61岁）。平均肿瘤直径2．4cm（1．0～4．0cm）。病理分期T1N0M047例，双侧肾癌1例。评估肾蒂阻断时间、术后并发症及局部复发情况。结果 48例手术均顺利完成，肾蒂阻断时间平均18min（12～26min）。术后出血3例、漏尿1例。平均随访21个月，1例术后6个月局部复发行根治性手术，1例出现远处转移而死亡，余未见复发或远处转移。结论 保留肾单位的肾部分切除治疗小肾癌安全有效，手术指征可扩展至对侧肾脏正常的患者。     

Nephron-sparing surgery for renal tumours using selective renal parenchymal clamping

OBJECTIVE: To describe a technical modification that facilitates nephron-sparing surgery (NSS) for renal tumours, without clamping the renal pedicle or promoting renal surface hypothermia. PATIENTS AND METHODS: Seventeen patients with renal tumours had NSS using the selective renal-parenchymal clamping technique. In 11 patients the tumour was polar and in six it was central. The mean (range) size of the tumours was 3.6 (2-6) cm. The technique was performed using one or two large Satinsky vascular clamps. Time was not limited as there was no clamping of the renal pedicle, or renal hypothermia. RESULTS: The mean (range) operative duration was 190 (120-300) min. Only one patient needed a blood transfusion. There were no complications in 13 patients after NSS. The mean (range) hospital stay was 5 (3-12) days. The pathological examination detected malignant tumours in 13 patients, and a microscopic examination showed adequate surgical margins in all. The mean (range) follow-up was 24.5 (4-60) months. No patients required haemodialysis immediately after surgery or later. CONCLUSIONS: Selective renal parenchymal clamping is a simple and efficient technical manoeuvre that facilitates NSS without dissection or clamping of the renal pedicle. Time is not limited as the ischaemia is limited to the tissue surrounding the tumour. The operative duration and blood loss are acceptable and the complications similar to those with the conventional technique. The size and position of the tumour could be limiting factors to this technique.     

保留肾单位手术治疗肾错构瘤的探讨

目的：探讨保留肾单位手术治疗肾错构瘤的可行性和有效性。方法：采用保留肾单位手术治疗30例肾错构瘤患者,其中29例行肾部分切除术．1例行选择性动脉栓塞术。结果：30例患者共切除瘤体31个．直径2～23cm，术后无一例发生出血、尿瘘．术后肾功能相对稳定。随访1～142个月．未见肿瘤局部复发。结论：保留肾单位手术治疗肾错构瘤成功率高．有效地控制出血和保护肾脏功能是手术成功的关键。     

Nephron-sparing surgery for renal cell carcinoma with venous involvement

A nephron-sparing operation recently has been shown to provide extended survival free of disease in selected patients with localized renal cell carcinoma, particularly for tumors of lower stage. To define better the role of conservative surgical treatment in more locally advanced renal cell carcinoma we reviewed 9 patients with venous tumor involvement in solitary functioning kidneys who underwent a nephron-sparing operation. Complete tumor resection with adequate preservation of renal function was accomplished in all cases. Of the 9 patients 5 had no evidence of disease 7 to 93 months (mean 33.2 months) postoperatively. The remaining 4 patients died of metastatic renal cell carcinoma 17 to 47 months (mean 35.5 months) postoperatively, 2 of whom had concomitant local recurrences in the renal remnant. Based on previously reported results of total nephrectomy for renal cell carcinoma with venous involvement and the morbidity associated with renal replacement therapy, we believe that a nephron-sparing operation is a viable option in the management of these patients.     

Nephron-sparing surgery for unilateral primary renal tumor in children

PURPOSE: Definition of the role of nephron-sparing surgery (NSS) in the treatment of children with primary unilateral renal tumor (URT). METHODS: Between January 1992 and June 2000, 28 children with URT were admitted to our surgical unit. Criteria for selection of patients eligible for NSS were at least 50% of affected kidney preservable and stage I at surgery (frozen section biopsies from regional lymph nodes, perirenal fat, and surrounding renal parenchyma). Preoperative 2-drug chemotherapy was given to all patients more than 6 months of age. Between 1992 and 1995, 3-drug chemotherapy was used after NSS. Thereafter, following NSS, 2-drug chemotherapy was given if no microscopic residual disease was found on final histologic examination. RESULTS: NSS was feasible in 10 of 28 children (35%). Enucleation of 6 tumors (1 metachronous) was performed in 5 patients. NSS was elective in 5 patients, mandatory in 3 patients (1 with aniridia and genitourinary anomalies, 1 with chronic glomerulonephritis, 1 with bilateral hyperplastic nephroblastomatosis), and advisable in 2 patients (1 with familial vesicoureteric reflux and 1 with cystic nephroma). Seven children had standard histology nephroblastoma, 1 highly differentiated epithelial type nephroblastoma, 1 oncocytoma, and 1 cystic nephroma. The only post-NSS complication was macroscopic hematuria in 1 patient. None of the patients had a relapse. All children are alive and disease free with good functioning of the affected kidney after NSS, at a mean follow-up of 40.7 months (range, 2 to 100 months). CONCLUSION: NSS should be considered in selected children with URT, especially in patients with increased risk for metachronous tumor or renal disease, and in patients with benign or low-grade malignant URT.     

Nephron-sparing surgery for renal cell carcinoma in the solitary kidney

OBJECTIVE: Partial nephrectomy in solitary kidneys carries the risk of tumour progression as well as loss of renal function. We evaluated complications and outcome in patients with renal cell cancer in solitary kidneys who were treated by means of nephron-sparing surgery. MATERIAL AND METHODS: Between 1993 and 2003, 38 patients with renal cell carcinoma in a solitary kidney underwent nephron-sparing surgery (partial nephrectomy, n = 37; work-bench resection, n = 1). Of these patients, 21 had asynchronous and eight had synchronous bilateral tumours and underwent contralateral radical nephrectomy. The variables examined were tumour size, disease progression, pre- and postoperative renal function and early (within 30 days of nephron-sparing surgery) and late complications. RESULTS: After a mean follow-up period of 41.7 months (range 8-93 months) the mean serum creatinine level had increased from 1.25 mg/dl preoperatively to 1.62 mg/dl postoperatively. Seventeen patients retained normal renal function and 21 developed some degree of renal insufficiency. New-onset chronic renal insufficiency after nephron-sparing surgery with creatinine levels >2 mg/dl was the only late complication observed, occurring in 10 cases. None of the patients required dialysis. Transient urinary leakage was the most frequent early complication, occurring in four cases. Recurrence and/or progression were seen in six patients: four with local recurrence (three of whom also had distant metastases) and two with pure metastatic progression. Nephron-sparing surgery was repeated for the patient with isolated local tumour recurrence. The mean tumour size was 3.8 cm (range 0.7-9.9 cm). Tumour size was markedly greater in patients who developed disease progression (6.2 vs 3.5 cm) and in those who developed renal insufficiency (5.2 vs 3.3 cm). CONCLUSIONS: Nephron-sparing surgery for renal cell carcinoma involving a solitary kidney provides effective curative treatment for small tumours, with preservation of renal function. However, patients who undergo partial nephrectomy for locally extensive tumours are at high risk of disease progression.     

Nephron-sparing surgery

Over the last two decades, nephron-sparing surgery has gained more and more importance. Initially it was done for imperative indications to preserve the remaining function of solitary kidneys. Today, because of favourable oncological results, elective nephron-sparing surgery is increasingly performed. According to the latest European Association of Urology guidelines on renal cell carcinoma, nephron-sparing surgery for tumours less than 4 cm with a healthy contralateral kidney is considered the standard therapeutic option because of excellent postoperative outcome and favourable oncological results. At major urological institutions, nephron-sparing surgery is even offered to patients with tumours larger than 4 cm (easy access, with partial resection deemed oncologically and technically feasible) for so-called extended elective indications. This review summarises the indications, perioperative management, various surgical approaches and techniques, and oncological results for nephron-sparing surgery, briefly highlighting data from our own institution.     

Nephron-sparing surgery for de novo renal cell carcinoma in allograft kidneys

Renal cell carcinomas account for 4.6% of post-transplant cancers, 10% of which occur in allograft kidneys. We report three such cases among kidney grafts that were performed or followed from 1970 to 2004. In all patients, we performed a partial allograft nephrectomy after consideration of the tumor size, location, and absence of metastases and local extension. Renal function has remained stable, and there has been no sign of graft rejection, tumor recurrence or metastases. The surgery was technically feasible without exposing the patients to increased postoperative risks. The lateral, peripherally located tumor allowed excision without renal hilar dissection or entry into the collecting system. In agreement with data emerging from the literature, the present cases confirm that even in the setting of long-standing immunosuppression, de novo RCC of the kidney graft warrants a minimally invasive approach to spare patients graft loss and return to hemodialysis.     

关于肾细胞癌保留肾单位手术若干问题的最新进展

近年来保肾手术已广泛用于早期肾癌的手术治疗,尤其在对侧肾脏正常的病例中。本文综述有关保肾手术的若干热点问题,包括选择性保肾手术的指征、安全切缘、切缘冰冻病理以及多中心病灶、远期效果、随访原则等,并对上述问题加以探讨。     

Incidental angiomyolipoma resected during renal surgery for an enhancing renal mass

OBJECTIVE

To review the outcomes of surgery for renal angiomyolipoma (AML, a benign renal neoplasm that often appears as an enhancing renal mass on imaging) removed at a centre that manages AML conservatively, as typically the presence of tumour fat content detected on imaging leads to its diagnosis, but occasionally these tumours resemble conventional RCC, leading to their surgical extirpation.

PATIENTS AND METHODS

We retrospectively report data on 44 consecutive patients who had renal surgery with a pathological diagnosis of AML at our institution from 1988 to 2008. Patient demographics, intraoperative variables and postoperative outcomes are reported.

RESULTS

Of the 44 patients (40 women, 91%, and four men, 9%), most were asymptomatic (36, 82%), were unsuspected on imaging (40, 91%), had a solitary lesion (38, 86%), and all had a normal contralateral kidney. Patients had either a partial nephrectomy (38, 86%) or radical nephrectomy (six, 14%). The median (range) tumour size was 2.5 (0.6–19) cm. Perioperative complications occurred in 10 patients (23%), and a total of seven renal units (16%) were lost. Ten patients (23%) had chronic kidney disease (CKD) before surgery, while new onset CKD developed in six (14%) at the last follow‐up. There were no recurrences and there was one unrelated death at a median follow‐up of 28 months.

CONCLUSIONS

AML is a benign renal neoplasm that should be treated conservatively. Surgical intervention should be avoided, when possible, as it can lead to perioperative complications, loss of renal units, and development of CKD.     

Nephron-sparing surgery

The curative management of renal cell carcinoma remains surgical. Recent advances in imaging and increased use of cross-sectional imaging modalities have led to an increased detection of incidental renal cell carcinomas. There is little debate regarding the role of nephron-sparing surgery (NSS) when absolutely indicated. Radical nephrectomy is still considered by many as the treatment of choice for localized renal cell carcinoma in the setting of a normal contralateral kidney. However, there is growing evidence that in the correct patient, the use of NSS in this setting is justified. Therefore, the indications of NSS have evolved in the past decade. Recent data indicate that radical nephrectomy and NSS provide effective and equivalent curative treatment for most renal cell carcinomas, especially those 4 cm or smaller. These data, along with new, refined surgical techniques, new studies regarding the biology of renal cell carcinoma and true incidence of occult multifocality, and earlier diagnosis make NSS an attractive consideration for the practicing urologist.     

Nephron-sparing surgery for renal tumours: acceleration and facilitation of the laparoscopic technique

OBJECTIVE: Present our surgical technique for and experience with laparoscopic partial nephrectomy (LPN) for renal tumours during warm ischaemia. METHODS: Twenty-five patients underwent LPN during warm ischaemia via a transperitoneal four-trocar approach. Mean tumour size was 26.2+/-7.3mm (range: 11-39 mm). Sixteen tumours were exophytic, 7 endophytic, and 2 central. The renal vessels were secured by an umbilical tape and occluded by a self-made Rumel tourniquet. Tumours were excised with a cold Endo-shear. The interstitial tissue and collecting system was closed using a running suture secured by two resorbable clips. Parenchymal edges were approximated using a running suture over a haemostatic bolster. The threads were secured by non-resorbable clips. During follow-up, renal function was evaluated by determination of serum creatinine, (99m)Tc-mercaptoacetyltriglycine scintigraphy, and parenchymal transit time. RESULTS: Mean ischaemia time was 28.9+/-5.2 min (range: 19-40 min) and the mean blood loss was 177.4+/-285.5 ml (range: 50-1500 ml). No intraoperative complications occurred and no patient needed conversion to open surgery. Surgical margins were negative in all patients. One postoperative surgical-related perirenal haematoma occurred, which was treated conservatively (no transfusions required). None of the patients had a urinary leak. During a mean follow-up of 6.2 mo (range: 1-15 mo), none of the patients had local or port-site recurrence or distant metastasis. Parenchymal transit time was increased in 1 of 10 investigated patients (ischaemia time: 26 min), indicating ischaemic parenchymal damage. CONCLUSION: Our technical refinements for LPN during warm ischaemia have widened indications to more complex tumours. The use of clips rather than knot tying made the procedure easier and faster and allowed completion of the suturing during an acceptable warm ischaemia time. The self-made Rumel tourniquet is safe and efficient for vessel control and occlusion. These improvements increase feasibility so that LPN can be used by more laparoscopic urologic surgeons.     

Nephron-sparing surgery in a case of giant renal hydatid cyst

We report a case of a centrally located giant renal hydatid cyst managed successfully by excision of the cyst alone and preserving the renal parenchyma after clamping the main renal artery. Follow-up IVP showed good function.